Basic Information
| Provider Information | |||||||||
| NPI: | 1457305310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILKS | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 JONES FERRY RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199335168 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 JONES FERRY RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199335168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29687 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 87616 | 01 | NC | BCBS | OTHER |